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ABSTRACT

Objectif : Déterminer les principales caractéristiques des muscles stabilisateurs afin d’éclairer la formulation d’une définition des muscles stabilisateurs basée sur les éléments de preuve disponibles. Méthodes : On a effectué, dans des bases de données électroniques, une recherche systématique de publications pertinentes depuis le début jusqu’en juin 2013 en utilisant des mots clés liés à la stabilité, aux muscles et aux caractéristiques des muscles stabilisateurs. Les études comportant au moins une caractéristique d’un muscle stabilisateur ont été incluses. Pour les fins de l’évaluation de la qualité, on a classé tous les articles inclus comme études expérimentales ou traduisant une opinion. On a évalué la qualité méthodologique au moyen d’une liste de contrôle personnalisée et analysé les données au moyen d’une synthèse narrative comportant une analyse de contenu. Le nombre d’articles présentant des éléments de preuve directs à l’appui de l’existence d’un lien entre la caractéristique et la stabilité de l’articulation ou un élément de preuve indirect indiquant qu’un muscle considéré comme muscle stabilisateur présentait cette caractéristique a déterminé le niveau d’importance de la caractéristique en question pour les muscles stabilisateurs. Résultats : Au total, 77 études répondaient aux critères d’inclusion. Le nombre le plus élevé d’articles présentant des éléments de preuve à l’appui du fait qu’une caractéristique musculaire en particulier joue un rôle stabilisateur portait sur les caractéristiques biomécaniques (27 articles), neurologiques (22 articles) et anatomiques/physiologiques (4 articles). Conclusion : Compte tenu d’une synthèse des éléments de preuve à l’appui tirés des publications, il est possible de définir les muscles stabilisateurs comme des muscles qui contribuent à la rigidité d’une articulation par cocontraction et qui sont activés rapidement en réponse à une perturbation par un mécanisme de contrôle de l’alimentation et de la rétroaction. Ces résultats peuvent aider les chercheurs à étudier les muscles qui montrent ces caractéristiques afin de déterminer si des muscles en particulier ont un rôle stabilisateur plutôt que moteur au cours du fonctionnement normal.

Mots clés : articulations, muscles, instabilité des articulations

Stability is a commonly discussed concept in physiotherapy and rehabilitation. A lack of stability is recognized as the primary complaint in conditions such as dislocated shoulder, where intervention after joint reduction may focus on an exercise programme to maintain stability through muscle action. The broader concepts of stability, such as “motor control” and “core stability,” have evolved as the fundamental principles behind many rehabilitation and preventive programmes.13 Although several attempts have been made to define stability, no single, universally accepted definition is available.

Joint stability has been defined as “the strength of the bond between the bones in a joint.”4(p.105) Several theories about stability have been advanced in the literature, including the model of active, passive, and neural subsystems;5,6 local and global stability systems;2,7,8 core control;3,7 transarticular muscle forces;9 dynamic stabilization;10 and sensory-motor control.2,8

All of these concepts and theories strongly suggest that muscles and motor control play an important role in joint stability. For example, many studies have reported that the rotator cuff muscles act as dynamic stabilizers at the glenohumeral joint;11,12 similarly, the stabilizing systems of the lumbar spine include muscles that control movement and are essential to normal functioning of the spine.13,14 On this basis, many rehabilitation programmes aim to improve function and motor control of these stabilizer muscles to provide joint stability and protect from injuries.13

While the importance of muscles to joint stability is recognized, the exact definition and characteristics of stabilizer muscles are less clear and lack supporting evidence.7,8 Given the apparent importance of stabilizer muscles to normal joint function, understanding their characteristics and, more importantly, exploring the supporting evidence for these characteristics will help identify such muscles when diagnosing musculoskeletal disorders and inform the design of successful rehabilitation programmes.

The aim of our systematic review, therefore, was to determine the key characteristics, based on available evidence, of stabilizer muscles to inform the development of a definition of stabilizer muscles.

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Methods

Data sources and search

We systematically searched four electronic databases (AMED, CINAHL, Medline, and SPORT Discus) for relevant literature from the databases’ inception to June 2013 using three search concepts linked together with the AND operator and combining keywords within each concept with the OR operator (see online table for keywords). The first search concept used the term muscl*; the second used terms related to stability, such as stabiliz*, control, or stiffness. Terms used for the third search concept, characteristics, were derived from characteristics commonly mentioned in the literature, such as feed-forward and feedback, muscle recruitment, and muscle architectural characteristics.

Study selection

After the initial online searches, we removed all duplicate articles. The selection criteria (Box 1) were then applied to the titles and abstracts by two reviewers working independently. All potentially eligible studies were selected for a full-text review and were assessed by two reviewers who independently reapplied the eligibility criteria. Inclusion in the review was then determined by consensus. Studies were included if they described at least one characteristic of a stabilizer muscle, based on the categories of classification suggested by Ng and colleagues: anatomical/physiological, neurological, or biomechanical.13

Box 1

Selection Criteria

Inclusion criteriaExclusion criteria
• Studies that provided an implied definition of a stabilizer muscle including at least one characteristic:• Intervention studies that did not provide any information about the characteristics of a stabilizer muscle
– Anatomic/physiologic• Studies that were mainly focused on other muscle characteristics,
e.g., delayed onset muscle soreness
○ e.g., Fibre type
– Neurological• Animal studies
○ e.g., Timing of onset• Abstracts
– Biomechanical• Dissertations
○ e.g., Angle of pull
• English language only
[Open in a separate window](/pmc/articles/PMC4403366/table/d35e325/?report=objectonly)

Quality assessment

We classified the articles as either opinion-based or experimental studies. Since the existing quality appraisal tools were inappropriate for this type of review, we created a customized checklist (see Table 1) to address key sources of bias.15 Opinion-based studies were considered less subject to bias if they followed a systematic search strategy, and experimental studies were considered less subject to bias if they provided supporting evidence. Supporting evidence was either direct in that it supported the link between the characteristic and joint stability or indirect in that it showed that a muscle considered to be a stabilizer has that characteristic (Table 1). No studies were excluded based on the outcome of the quality assessment.

Table 1

Characteristics of Stabilizer Muscles as Described in Current Literature and Quality Assessment of the Included Studies

Study
type
Biomechanical
characteristics
Neurological
characteristics
Anatomical/
physiological
characteristics
Quality assessment
ReferenceJoint
compression
Muscle
mechanics
Neuromuscular
control
RecruitmentO1O2O3E1
Arbanas (2009)29EN
Bergmark (1989)7ONYN
Boettcher (2010)12EN
Bogduk (1992)30EN
Borghuis (2008)1ONYN
Brown (2005)82E✓✓✓✓✓Y
Brown (2005)31E✓✓✓Y
Lin (2011)33E✓✓✓Y
Cheng (2008)34E✓✓Y
Cholewicki (2002)37E✓✓✓✓✓Y
Cholewicki (1996)35E✓✓✓Y
Cholewicki (1997)36E✓✓✓Y
Comerford (2001)2ONYN
Comerford (2001)8ONYN
Cowan (2002)38EN
Crisco (1991)39EN
Danneels (2001)40E✓✓✓✓✓✓N
Davarani (2007)41E✓✓✓✓✓✓N
Day (2012)11E✓✓✓✓N
Delahunt (2006)42E✓✓✓N
Franklin (2007)43E✓✓✓✓✓✓N
Gardner-Morse (95)44E✓✓✓N
Gardner-Morse (98)45E✓✓✓✓✓✓N
Gibson (2004)81E✓✓✓✓N
Granata (2001)46E✓✓N
Granata (2001)48E✓✓✓✓✓✓Y
Granata (2004)47EN
Granata (2007)49E✓✓✓✓Y
Guieterrez (2009)19ONYN
Hides (2008)50EN
Hodges (1999)20ONYN
Hodges (1998)52E✓✓✓✓✓✓Y
Hodges (1996)51E✓✓✓✓✓✓Y
Holmes (2009)21ONYN
Hossain (2005)22ONCTN
Hungerford (2003)53EN
Huxel (2008)54E✓✓✓✓✓Y
Jemmett (2004)55E✓✓Y
An (2002)18ONCTN
Kalimo (1989)23ONCTN
Kibler (2006)3ONYN
Lee (2000)58E✓✓✓Y
Lee (2002)59E✓✓✓Y
Lee (2006)56E✓✓✓Y
Lee (2007)57E✓✓✓Y
Lin (2011)60E✓✓✓✓✓Y
MacDonald (2006)24ONYN
Macintosh (1986)61EN
Matějka (2006)62E✓✓✓Y
Mcgill (2003)10ONYN
Morris (2012)63EN
Ng (1998)13ONYN
Norris (1995)14ONCTN
Norris (1995)26ONYN
Norris (1995)25ONYN
O'Sullivan (1997)65EN
O'Sullivan (1998)64EN
Panjabi (1989)66EN
Panjabi (1992)5ONYN
Panjabi (1992)6ONYN
Panjabi (1994)27ONYN
Radebold (2000)67EN
Regev (2011)68E✓✓✓Y
Rodosky (1994)69E✓✓✓Y
Sakurai (1998)70EN
Silfies (2005)72EN
Silfies (2009)71EN
Sinkjær (1991)73E✓✓Y
Stokes (2000)74EN
Stokes (2011)75EN
van Dieën (2003)76E✓✓✓Y
Vera-Garcia (2006)77E✓✓✓Y
Ward (2006)78E✓✓✓✓✓Y
Ward (2009)79E✓✓✓✓Y
Wattanaprakomkul (2011)80E✓✓Y
Williams (2001)28ONYN
Total Count4030282310
Count of records with direct supporting evidence118733
Count of records with indirect supporting evidence35571
Total count of records with any supporting evidence141312104
[Open in a separate window](/pmc/articles/PMC4403366/table/T1/?report=objectonly)

O1=Was a specific search strategy described?; O2=Were important, relevant studies included?; O3=Did the authors check the quality of the included studies?; E1=Did they provide any supporting evidence in relation to stability?; E=experimental study; O=opinion-based study; ✓=characteristic reported; ✓✓= characteristic reported with indirect supporting evidence; ✓✓✓=characteristic reported with direct supporting evidence; Y=Yes; N=No; CT=Can’t tell.

Data analysis

We used a content analysis approach to collect data about characteristics of stabilizer muscles from selected studies. This involved applying the three principles of content analysis: (1) develop categories before searching for them in the data; (2) select the sample to be categorized; and (3) count or systematically record the number of times each category occurs.16

We first developed three categories of characteristics of stabilizer muscles—anatomical/physiological, neurological, and biomechanical—in accordance with the classification by Ng and colleagues.13 Individual sentences, terms, or paragraphs that related to a characteristic were identified in each article. Thereafter, we used an axial coding approach to link these selected characteristics of stabilizer muscles to the original three categories via sub-categories.17 For each study, consistent with the third principle of content analysis, we recorded the occurrence of stabilizing characteristics and whether or not the study found supporting evidence (direct or indirect) to link the characteristic to stability. The number of articles that provided supporting evidence linking a particular concept to stability determined its level of significance in describing a characteristic of stabilizer muscles.

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Results

Yield

Our initial searches identified a total of 2,079 articles. After applying our selection criteria, 77 studies were selected for review (see Figure 1).

Open in a separate windowFigure 1

Selection process for included studies.

Quality assessment

Of the 77 included studies, 21 were opinion-based studies,2,3,58,10,13,14,1828 and the remaining 56 were experimental studies11,12,2881 (see Table 1). Our quality analysis found that none of the opinion-based studies provided information on their search strategy or on the quality of the included studies; they provided only low-level evidence on the stabilizing characteristics of muscles, as they referred to studies that included experimental evidence based on other studies. Of the 56 experimental studies, 36 provided supporting evidence: 26 provided direct evidence to support a link between the characteristic and joint stability, and 10 provided indirect evidence that a muscle considered to be a stabilizer has that characteristic (Table 1).

Characteristics of stabilizer muscles

Axial coding identified 11 characteristics, which were grouped in sub-categories as required under the original three categories of the characteristics of stabilizer muscles (see Figure 2). Definitions of the key characteristics and their relationship to joint stability are presented in Box 2.

Open in a separate windowFigure 2

Characteristics of Stabilizer Muscles. Figures in parenthesis (a, b) represent the number of studies reporting that characteristic (a) and number of studies with supporting evidence (b).

PCSA=Physiological Cross Sectional Area

Box 2

Definitions of Muscle Characteristics and Their Relationship to Joint Stability

Online Table

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Notes

Physiotherapy Canada 2014; 66(4);348–358; doi:10.3138/ptc.2013-51

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